Citation Nr: 9806496 Decision Date: 03/04/98 Archive Date: 03/20/98 DOCKET NO. 94-27 301 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a heart disability, claimed as secondary to the service-connected bronchial asthma disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Crawford, Associate Counsel INTRODUCTION The veteran served on active duty from May 1943 to April 1946. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky in which entitlement to service connection was denied. Disagreeing with that determination, the veteran perfected an appeal therefrom. On appellate review in August 1996, the Board remanded the claim for additional development. After completing the requested development, in September 1997, the RO confirmed and continued the prior denial. The case has been returned to the Board for appellate review. It is also noted that the veteran’s claims file has been transferred to the RO in Cleveland, Ohio. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his cardiac disability is related to his service-connected bronchial asthma disability and prescribed medication. He asserts that because of the bronchial asthma disability and therapeutic drugs prescribed, he was hospitalized for an atrial fibrillation episode and currently has arteriosclerotic heart disease. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports the claim of entitlement to service-connection for a heart disability. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran’s appeal has been obtained. 2. Service connection for an asthma disability is in effect. 3. The veteran’s current heart disorder was aggravated by the service-connected asthma disability. CONCLUSION OF LAW The veteran’s heart disorder was aggravated by the service- connected asthma disability. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.310(a) (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Review of the record indicates that the veteran has submitted a well grounded claim. The VA, therefore, has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a). After reviewing the evidence of record, the Board is satisfied that all necessary evidence has been received and adequately developed. Id. In this case, the veteran contends that his heart disorder occurred as secondary to his service-connected bronchial asthma disability and prescribed medications therefrom. VA regulations provide that service connection may be granted for a disability resulting from personal injury incurred in the line of duty or for aggravation of a preexisting injury. 38 U.S.C.A. § 1110. The regulations also state that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service or aggravated by service. 38 C.F.R. §§ 3.303. Service connection may also be granted for certain chronic diseases, including arteriosclerosis, if manifest to a degree of 10 percent or more within one year from the date of separation from such service. 38 U.S.C.A. §§ 1101, 1112, (West 1991 & Supp. 1997); 38 C.F.R. §§ 3.307, 3.309 (1996). In addition, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is granted for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. 3.310. Further, if a service-connected disability aggravates a nonservice-connected disability, service connection may be granted for increment in severity of the nonservice-connected disability attributable to service-connected disability. The term “disability” refers to impairment of earning capacity, in that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). The VA must determine whether evidence supports the veteran’s claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In this case, it is initially noted that service connection for moderate bronchial asthma was granted in May 1946. Regarding the heart disorder, the service medical records do not document any complaints of or findings associated with a heart disability. On entrance examination in October 1942 and discharge examination in April 1946, clinical findings were normal. The record then shows that on VA examinations in June 1951, September 1956, December 1958, and May 1960, the veteran generally complained of chest pain and fullness of the chest. But, on clinical evaluations, the cardiovascular system was normal and reports of chest x-ray studies were negative. No relevant diagnosis was made. VA outpatient treatment reports from May 1972 to October 1973 show that the veteran received treatment for symptoms associated with asthma. The reports do not show complaints of or findings of a heart disorder. In addition, the May 1974 VA examination report is silent with regard to a heart disorder. VA hospital and outpatient treatment reports dated from April 1990 to June 1991 show that the veteran complained of chest pain. The reports essentially show that in April and October 1990, examination of the veteran’s heart was normal. The reports then show that in June 1991, the veteran was hospitalized for a “new onset” of atrial fibrillation. At that time, it was noted that the veteran by history may have been experiencing periodic bouts of atrial fibrillation over some time even though by history, this was the veteran’s first presentation for medical care. It was then noted that the veteran gave a history of rhythmic behavior which could have been represented by evidence of sick-sinus syndrome. It was also noted that the veteran had many risk factors for coronary artery disease (CAD), including a chronic obstructive pulmonary disease (COPD)/asthma etiology that must also be considered. The reports then generally show that on the veteran’s June 1991 hospital discharge summary report, examination of the heart showed an irregularly irregular rhythm without evidence of murmur, rubs, or gallops. The diagnoses were one episode new onset of atrial fibrillation, non-insulin diabetes mellitus, and chronic obstructive pulmonary disease. Textbook materials discussing medications prescribed for the veteran’s bronchial asthma disability are also of record. At VA examination in September 1992, the veteran, in relevant part, stated that he was recently hospitalized for tachycardia which was later determined to be an atrial fibrillation and treated with medication. During the interview, the veteran complained of shortness of breath on mild exertion and of the inability to climb stairs. On examination, the heart sounds, rate and rhythm were normal, and evidence of fibrillation was not present. However, the peripheral vessels were arteriosclerotic. The diagnoses were chronic bronchial asthma, arteriosclerotic heart disease with previous episode of atrial fibrillation. After examination, in the comment section, the examiner stated that it was entirely possible that if the veteran’s asthma was as pronounced as it seemed, a chronic strain on the heart could have resulted. The examiner also noted that the veteran was seventy-one years old with advanced arteriosclerosis. On VA examination in December 1992, the veteran heart was reexamined. It was noted that since the last examination, the veteran had not experienced any episodes of atrial fibrillation for which he was previously hospitalized. The examiner then reiterated that he did not feel that the veteran had right heart failure, as was occasionally seen with a severe asthma disability, but the veteran had poor expiratory excursion and frequently complained of shortness of breath. The examiner also recalled that on evaluation, the veteran’s cardiac rhythm was completely normal without fibrillation. However, the peripheral vessels were arteriosclerotic and expiratory wheezes of the left side were heard. In addition, the electrocardiogram (EKG) was abnormal, as a nonspecific T-wave abnormality and sinus rhythms had replaced atrial fibrillation, and the ventricular rate had decreased to 36 beats per minute. The diagnosis was arteriosclerotic heart disease with previous single episode of atrial fibrillation; arteriosclerosis, generalized; chronic obstructive pulmonary disease; and bronchial asthma. At his personal hearing in October 1993, the veteran stated that the medication prescribed for his asthmatic disorder caused the prior heart attack. After taking that medication, the veteran stated that he experienced tremors, irregular heartbeats, and weakness. A heart disorder was diagnosed in the late 1980’s. The veteran then listed the medications he had taken after service and described symptoms experienced after taking prescribed medication. As a result of his heart disability, the veteran stated that he experienced chest pain, an increased heartbeat, and trembling. VA outpatient treatment reports from September 1991 to October 1993 are also of record. Those reports essentially show that the veteran received treatment for non-related medical disorders. On VA examination in December 1993 continued complaints of chest pain with a trembling sensation were documented. At that time, the veteran also stated that his heartbeat occasionally became faint and stopped for 10 to 15 seconds. He also experience difficulty with visual and auditory components. The examiner then noted that a Holster Monitor showed a predominantly normal sinus rhythm with evidence of two prior episodes of supra-ventricular tachycardia at 140 and 220 beats lasting 3 and 14 beats. On cardiac examination, the point of maximal impulse was palpable in the 4th intercostal space and midclavicular line. S1 and S2 sounds were normal without murmurs, rubs, or gallops. Sinus rhythm was also normal. The EKG showed abnormal findings at the sinus tachycardia and evidence of a tachycardia wave that was considered inferolateral ischemia. Evidence of an inverted T wave which replaced nonspecific T wave abnormality in inferior leads was also detected. The diagnoses were asthma with both restrictive and obstructive components by pulmonary function studies. After examination, the examiner stated that the veteran was in normal sinus rhythm however he did have one documented episode of atrial fibrillation in 1991 that could have been attributable to his intrinsic lung disease. The examiner also noted that evidence of cor pulmonale, chronic sinusitis, hypertension, and non-insulin dependent diabetes was not present on examination. The examiner then concluded that the veteran’s episode of atrial fibrillation was most likely due to asthma with its restrictive and obstructive components. VA hospital reports and outpatient treatment reports from January 1993 to August 1996 generally show that the veteran received treatment for numerous disorders, including COPD. The reports also show that in October 1995, the veteran was hospitalized for complaints of an irregular heartbeat. At that time, it was noted that the veteran was in atrial fibrillation and that an ECG showed atrial fibrillation with a ventricular rate of 135 with inverted T waves on inferolateral leads. Inverted T waves were also present on the baseline ECG. The diagnoses were atrial fibrillation, diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. On VA examination in February 1997, the examiner recalled the veteran’s medical history which included diabetes mellitus, asthma, hypertension, and coronary artery disease status post myocardial infarction in 1991. He also noted that the veteran had a previous history of atrial fibrillation and COPD and that the veteran’s current medications included Digoxin, Methocarbamol, Glipizide, Beclomethasone nasal inhaler, Beclomethasone oral inhaler, and Albuterol inhaler. During the interview, the veteran complained of daily chest discomfort associated with anxiety and dyspnea. He also complained of chest discomfort that occurred while sedentary and paroxysmal nocturnal dyspnea. He denied experiencing orthopnea. Examination of the cardiovascular system revealed a midclavicular point of maximal impulse with a regular S1 and S2 rate and rhythm. Evidence of murmurs, rubs or gallops was not present. In addition, chest x-rays were normal and ECG findings were essentially normal except for a T-wave inversion in the inferior leads. The diagnoses were diabetes mellitus; hypertension, controlled on current regimen; history of asthma/chronic obstructive pulmonary disease; history of atrial fibrillation, currently in normal sinus rhythm; and coronary artery disease status post report of myocardial infarction in June 1991. ECG evidence of T-wave inversion in inferior leads consistent with ischemia or previous subendocardial myocardial infarction and evidence of Q-wave myocardial infarction not present were also noted. In an addendum to the 1997 examination report, the examiner recalled the aforementioned findings on the February 1997 report. The examiner also discussed the veteran’s history from the claims folder. The examiner stated that the veteran had multiple risk factors for coronary artery disease including hypertension and diabetes mellitus, but the veteran denied a familial history of coronary disease, tobacco use, and an elevated cholesterol level. The examiner then stated that the two cardiac risk factors of hypertension and diabetes mellitus were more likely than not the etiologies of the veteran’s coronary artery disease. The coronary artery disease was not a direct result of the asthma disability or medications used to treat it. However, the examiner then stated that the veteran’s obstructive lung disease, particularly when in exacerbation, may have acutely and chronically aggravated the known coronary artery disease. With that in mind, the examiner added that medications used to treat such exacerbations could have also aggravated the veteran’s underlying cardiac disease. Specifically, the examiner noted that the beta-agonist medications could have increased the veteran’s heart rate and blood pressure which would certainly aggravate underlying coronary artery disease. In summarizing the foregoing, the examiner reiterated that the veteran’s coronary artery disease was not a direct result of the veteran’s service-connected obstructive lung disease or the medications prescribed therefrom. The examiner, however, stated that it was more likely than not that the veteran’s underlying obstructive lung disease, particularly when in exacerbation and the medications used to treat the underlying obstructive lung disease, namely the beta-agonist medications, would be more likely than not to acutely and chronically aggravate the veteran’s underlying coronary artery disease. After reviewing the aforementioned evidence of record, the Board notes that the veteran cannot establish entitlement to service connection for a heart disability on a direct basis, as the record overall does not show the veteran’s current heart disability had its onset during service and in-service occurrence may not be presumed. In addition, the record does not show that the veteran’s current heart disability was caused by the service-connected asthma disability. However, after carefully weighing all of the evidence of record, the Board concludes that the veteran’s service-connected asthma caused an aggravation of the underlying heart disability. Thus, in accordance with Allen v. Brown, 7 Vet. App. 439, service connection is warranted for the increment in severity of the nonservice-connected disability attributable to the service-connected disability. As noted above, if a service- connected disability aggravates a nonservice-connected disability, service connection may be granted for the increment in severity of the nonservice-connected disability attributable to the service-connected disability, regardless of whether the additional impairment is itself a separate disease or injury caused by the service-connected condition. Allen, supra. In this case, the record shows that the veteran’s testimony and assertions expressed on appeal are credible and probative in light of the clinical evidence. The clinical evidence shows that the veteran’s heart disorder has progressively increased in severity. In addition, in February 1997, a VA examiner stated that it was more likely than not that the veteran’s underlying obstructive lung disease, particularly when in exacerbation and the medications used to treat the underlying obstructive lung disease, namely the beta-agonist medications, would more likely than not acutely and chronically aggravate the veteran’s underlying coronary artery disease. While the Board acknowledges that the examiner was unclear as to what extent the veteran’s heart disability has been aggravated, he did acknowledge that the veteran’s chronic obstructive pulmonary disease disorder more likely than not aggravated the heart disorder. Therefore, based on the foregoing medical assertions and the entire evidence of record, the Board concludes that the evidence, viewed objectively, reasonably supports the veteran’s claim. The appeal is granted. ORDER Entitlement to service connection for a heart disability is granted. ROBERT E. SULLLIVAN Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -